Regional Hep A Outbreak Linked to the Ohio Valley Addiction Crisis

An outbreak of Hepatitis A that has been growing in the Louisville area since last summer reached a new peak recently with a trip notice from Indiana health officials. They told Hoosiers to go to Kentucky to get a Hep A vaccine.

"Let me say it's safe to travel to Kentucky, and it's safe to attend the Kentucky Derby," Howard said through the official YouTube channel.

The Commissioner of Public Health of Kentucky, Jeffrey Howard. (Still from the KY Department of Health video)

Later that same day, health officials in West Virginia announced an outbreak of hepatitis A in Kanawha and Putnam counties.

What looked like an isolated rash of cases in some Kentucky counties has now become a multi-state regional outbreak, with almost 500 cases in four states and the numbers increasing daily … As with the more recent groups of cases of HIV and high risk of hepatitis C, this latest outbreak of hepatitis A is also closely related to the addiction crisis in the region.

The immediacy and tragedy of overdose deaths in the Ohio Valley have overshadowed the risks of infections related to the opiate epidemic. But with this latest outbreak, it is clear that the disease has been added to overdoses as another threat to public health from the addiction crisis.

Rapid Spread

West Virginia Public Health Commissioner, Dr. Rahul Gupta, said fast action is crucial. West Virginia declared an outbreak when 20 cases appeared in two counties. Generally, he said, the total number of state cases in a year will be kept in single digits.

"One of the things we understand in public health is that when we have an outbreak of a disease, it can certainly accumulate a number of people having that disease very quickly," said Gupta.

Dr. Rahul Gupta is a commissioner of the West Virginia Office of Public Health, which has the highest overdose mortality rate in the country. (Ashton Marra, courtesy of WVPB)

In all affected states of the region, infection rates are well above normal. Ohio, which has about four dozen cases, has not declared an outbreak. But the cases of Ohio in the last four months already exceed the total cases of the state last year.

Kentucky has reported more than 370 cases since an outbreak was declared last summer. In previous years, the annual average had been about 20 cases.

Drug Connection

Another unusual factor in this outbreak of Hep A is that drug users are the core. In general, outbreaks of hepatitis A are caused by the ingestion of food contaminated with fecal matter. That often means that the food is contaminated where it is grown or that a food service worker inadvertently transmits the disease through a restaurant.

But this outbreak is different, as Gupta explained.

"Individuals who may have substance use disorder and may be using illicit drugs that can not maintain their personal hygiene," he said, "which puts them at greater risk of being infected with hepatitis A."

Health officials link the outbreak of hepatitis A with drug use and homelessness. (Wikimedia Commons)

Howard, in Kentucky, said the Centers for Disease Control are tracking outbreaks of Hep A in five states that show this unusual transmission. That means that Hep A now joins overdose, Hep C and HIV as health threats related to the addiction crisis. And the monitoring and treatment efforts are complicated by the regional nature of the infection.

"The biggest challenge we face is when the outbreaks cross state borders," he said. He noted an ongoing investigation of a group of HIV cases in northern Kentucky, which includes many travel communities linked to Cincinnati. That outbreak is also related to the use of needle drugs. "For the first time in Kentucky's history, we had HIV transmission and the most common risk factor was intravenous drug use," he said.

It also predicts more outbreaks linked to the addiction crisis.

"We will see more and more outbreaks in the coming months and years," he said.

Gupta said that death is relatively rare for Hep A. But the disease can be serious and last several weeks. Symptoms include fever, fatigue, nausea, vomiting, dark urine, jaundice, clay-colored stools and joint pain.

Hopeful signs

There are some signs of hope. First, the best prevention is a good hand wash with soap and water. Second, there is a Hep A vaccine. Since the vaccine became available in 1995, the cases of hepatitis A in the US UU They have decreased by more than 95 percent.

The CDC focuses vaccine supplies on the highest risk areas and says that manufacturers keep pace with demand, although the agency is monitoring supply situation. All regional health officials contacted by ReSource said vaccine supplies are adequate.

The CDC says that vaccines against Hepatitis A are in good supply. (User of Wikimedia Commons Kallerna)

Dr. James Gaskell is the health commissioner in the Health Department of Athens City-County in Ohio. He said that as the outbreaks came up recently he had his staff verify the available supply.

Gaskell is confident that an outbreak can be contained. But he said there are constant barriers to treatment in rural areas, barriers complicated by an increase in any infectious disease.

"Communication is a problem in Appalachia sometimes, even in today's world," he said.

Dr. Kraig Humbaugh is the Health Commissioner of Fayette County, Kentucky, and previously served as Kentucky's chief epidemiologist. He said it is difficult to know the true magnitude of any outbreak.

"That is true with almost any type of epidemic," he said. "There is always a certain percentage of cases that are hidden or not recognized."

For example, a 2016 outbreak related to imported foods caused reported cases of hepatitis A in the US UU They will increase 45 percent to approximately 2,000 cases. After adjusting for lack of reports, the CDC estimated that the actual number of new infections in 2016 was closer to 4,000.

Humbaugh said the current outbreak will attract more attention focused on health problems related to the region, and that could lead to more help.

"Unfortunately, there is a human cost and a financial cost, but it seems that we are receiving more attention."

Those costs, he said, will likely grow as the addiction crisis generates more infectious diseases. Outbreaks of diseases through the Ohio Valley.